Basic Information
| Provider Information | |||||||||
| NPI: | 1619568243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREVIK | ||||||||
| FirstName: | KILEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10238 NE EVERGREEN PARKWAY | ||||||||
| Address2: | UNIT 304 | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545777790 | ||||||||
| FaxNumber: | 9545777780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 SW MARLOW AVE | ||||||||
| Address2: | SUIT 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665234268 | ||||||||
| FaxNumber: | 9545777780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/09/2021 | ||||||||
| NPIReactivationDate: | 10/05/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106E00000X | Y |
No ID Information.